TITLE: Feasibility Study and Demonstration Project for Joint Military/Civilian Trauma Institute with a Burn Center

Transcription

1 AD AWARD NUMBER: DAMD17-03-C-0071 TITLE: Feasibility Study and Demonstration Project for Joint Military/Civilian Trauma Institute with a Burn Center PRINCIPAL INVESTIGATOR: Ronald M. Stewart, M.D. CONTRACTING ORGANIZATION: University of Texas Health Sciences Center San Antonio, Texas REPORT DATE: June 2006 TYPE OF REPORT: Annual PREPARED FOR: U.S. Army Medical Research and Materiel Command Fort Detrick, Maryland DISTRIBUTION STATEMENT: Approved for Public Release; Distribution Unlimited The views, opinions and/or findings contained in this report are those of the author(s) and should not be construed as an official Department of the Army position, policy or decision unless so designated by other documentation.

2 REPORT DOCUMENTATION PAGE Form Approved OMB No Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports ( ), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. 1. REPORT DATE (DD-MM-YYYY) 2. REPORT TYPE Annual 3. DATES COVERED (From - To) 26 May May TITLE AND SUBTITLE 5a. CONTRACT NUMBER Feasibility Study and Demonstration Project for Joint Military/Civilian Trauma Institute with a Burn Center DAMD17-03-C b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER Ronald M. Stewart, M.D. stewartr@uthscsa.edu 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION REPORT NUMBER University of Texas Health Sciences Center San Antonio, Texas SPONSORING / MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR S ACRONYM(S) U.S. Army Medical Research and Materiel Command Fort Detrick, Maryland SPONSOR/MONITOR S REPORT NUMBER(S) 12. DISTRIBUTION / AVAILABILITY STATEMENT Approved for Public Release; Distribution Unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT The purpose of this grant was to demonstrate the feasibility of a Trauma Institute and Burn Center with missions in patient care, research, and education. Goals met: a burn surgeon/director was recruited to improve sustainability of BAMC Burn Center; members have studied how combining resources will generate greater financial sustainability; a national trauma consultant reviewed the financial/economic status of each program and presented recommendations; an independent legal firm reviewed issues related to military and civilian doctors providing services across hospital lines and submitted recommendations; Surgical/Anesthesia Critical care fellowship program curriculum and rotation schedules have been integrated; patient databases and a regional trauma registry have been developed allowing use of regional data for research, both military and civilian; trauma and burn surgeons have submitted protocols for joint research and have conducted multi-site clinical research; the Foundation has been incorporated in Texas. Goals include: improved survival rates of military and civilian casualties, increased innovation in combat casualty care, improved educational experience for surgical/critical care trainees, improved pre-hospital evaluation and resuscitation, and improved mass casualty/disaster response capabilities. 15. SUBJECT TERMS Military/Civilian Trauma Institute; Burn Center 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT a. REPORT U b. ABSTRACT U c. THIS PAGE U UU NUMBER OF PAGES 19a. NAME OF RESPONSIBLE PERSON USAMRMC 19b. TELEPHONE NUMBER (include area code) Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std. Z39.18

3 Table of Contents Cover 1 SF Table of Contents.3 Introduction....4 Body.5 Key Research Accomplishments. 8 Reportable Outcomes.8 Conclusions..9 Appendices Physician Billing Report McDermott Will & Emery Executive Summary Surgical Critical Care Fellow Rotation Schedule Lecture Schedule

4 INTRODUCTION The University of Texas Health Science Center at San Antonio (UTHSC) proposed to utilize $1.814M in congressional funding to work collaboratively with Brooke Army Medical Center (BAMC) and the US Army Institute of Surgical Research, Wilford Hall Medical Center (WHMC) and University Hospital (UH). The awarded grant enabled these partners to create the Trauma Institute of San Antonio, Texas (),to conduct a financial and legal feasibility study and to demonstrate the capabilities of this joint military/civilian Trauma Institute with a Burn Center. Level I trauma and burn care by members cover Bexar County and State Trauma Service Area P (a 22 county region covering over 26,000 square miles) and beyond. The original Statement of Work described goals in the areas of patient care, research, and education, and specifically cited the need to secure and sustain the BAMC Burn Center. Before OIF/OEF hospitals cared for 8,000 trauma admissions a year, military and civilian, making this the largest trauma program in the US. When the grant was awarded, the resulting numbers of casualties from the global war on terrorism were not yet known. The combat casualty care training that military physicians, nurses, and others receive by caring for civilian trauma patients is critical to their training and ability to care for soldiers, sailors, airmen and marines wounded in the battlefield. Our proposal centered upon the historical strength of the burn center (US Army Institute of Surgical Research) at BAMC which is considered to be an important foundation for the s future. Funding from the Department of the Army was not considered to be sufficient to keep the burn center operational in its pre-war capacity; without this funding, the future of burn care for the military and civilian population in Bexar County and South Texas was threatened. Without a strong burn center, the army s commitment to burn care and research related to combat casualty care was also threatened. The collaborative nature of permits all partners to take advantage of their individual strengths in the areas of patient care, research and teaching and creates a joint operation that is thought to have stronger sustainability to ensure that Bexar County, South Texas and our nation s armed forces have access to much needed trauma and burn care services. is also improving the ability of UTHSC, BAMC and WHMC to provide stronger educational programs, thus enhancing mission readiness. Information gained and practices established from this review and feasibility study have benefited the larger endeavor of securing permanent comprehensive trauma services for Bexar County and South Texas through the collaborative efforts of UHS, UT, BAMC and WHMC.

5 Body: The Statement of Work includes these tasks which are addressed in detail in this section: 1. Financial/economic review of current Level 1 trauma centers, the BAMC Burn Center, and trauma surgeon groups, military and civilian. 2. Legal review of issues, obstacles, and implications for military and civilian business with Medicare, Medicaid, and third party insurance companies 3. Market analysis of San Antonio and South Texas to assess impact of population/demographic projections, based on both civilian and military populations 4. Business Plan to move forward with approved recommendations based on the above 5. Management of trauma surgeon resources 6. Other opportunities for collaboration In order to address these tasks, members formed a Board of Directors and Command Council, with a set of written Organizational Principles for management and governance of. Support staff includes the Project Coordinator, Academic Coordinator and Research Assistant. Financial/Economic Review The Board of Directors contracted with Bishop + Associates, a nationally recognized consultant specializing in trauma programs, to complete a financial and legal review of the current status of each trauma program, burn center, and trauma surgeon group or practice. The Board accepted the report and recommendations of the consultants. The scope of the project included estimating incremental reimbursement and recommended operational enhancements to billing activities by civilian and military physicians and hospitals. The Executive Summary is appended to this report and states that hospital and physician trauma and burn charges are sub-optimal, as shown in the table below. Recommendations pertaining to military physician billing for care provided to civilian trauma patients cannot yet be implemented due to regulatory constraints placed on military Medical Treatment Facilities. These regulations currently prohibit BAMC and WHMC ability to bill insurance programs and patients for specific physician services. Until such time as these constraints are removed, BAMC and WHMC cannot attain physician billing and revenue targets. staff has completed a project describing the necessary processes for physician billing by military treatment facilities that may be implemented following changes in regulations currently preventing this activity. When these changes occur, members will be able to fully pursue financial goals, which would result in incremental clinical income from physician services of over $6 million a year.

6 CURRENT & OPTIMAL TRAUMA AND BURN REIMBURSEMENT Current $ Optimal $ Change $ Hospital UHS 22,229,214 28,925,788 6,696,574 BAMC 6,347,148 13,279,655 6,932,507 BAMC Burn 4,450,293 7,112,023 2,661,730 WHMC 6,962,489 11,286,075 4,323,586 Total 39,989,144 60,603,541 20,614,397 Physician UPG 1,962,893 3,881,469 1,918,576 BAMC - 1,746,990 1,746,990 BAMC Burn - 576, ,000 WHMC - 2,270,979 2,270,979 Total 1,962,893 8,475,438 6,512,545 Trauma/ Burn Totals 41,952,037 69,078,979 27,126,942 Legal Review contracted with the Washington, D. C.-based legal firm of McDermott, Will & Emery to conduct a review of current federal and state laws and regulations specific to military and civilian billing/collection relationships with Medicare, Texas Medicaid, and third party commercial insurers. The review was completed and is specific to allowable practices and obstacles to be addressed. The Executive Summary of this report js appended. Key recommendations (Possible Action Items) address these questions: A. Can a civilian physician bill for trauma care provided at a military treatment facility? B. Can the military bill for trauma care provided to civilians? C. Can a military physician bill for trauma care at a trauma facility? The review also explored physician licensure and malpractice issues related to the same questions. Resident/Fellow Education members integrated the curriculum and clinical rotation schedules of Surgical and Anesthesia Critical Care Fellows under the guidance of the Program Directors and the Critical Care Education Consortium. Currently the program includes four (4) Surgical Critical Care fellows. members share responsibility for two (2) lectures per week, over 90 per year, delivered by video teleconference at all three sites to faculty, fellows, residents and students. Lectures are prepared and given by faculty and fellows. Those identified as core curriculum are recorded and stored on the website.

7 A reading compendium covering the required curriculum for surgical and anesthesia critical care fellows has been compiled and made available to fellows on-line. Program directors share responsibility for adding current relevant literature to the compendium and creating self-assessment questions that must be answered by the fellow for each article read. A clinical rotation schedule was developed for all critical care fellows so that ACGME guidelines and clinical needs are met at each facility. The lecture schedule and clinical rotation schedule are appended to this report. Clinical Research The Research Group includes surgeons, research nurses and staff from all facilities. The group meets on a biweekly basis to consider ideas for research as well as protocols under development at any one facility. During the three years of this grant has twice met the federal exception from informed consent requirements to obtain community consent in lieu of individual informed consent for clinical research. The first was for study of an artificial hemoglobin product developed by Northfield Laboratories and the second was for a study of lowdose Vasopressin, funded by the Office of Naval Research. has applied for NIH grants, sponsored studies, and grants from other agencies. Presently, one member/physician serves as Principal Investigator on each grant/study and receives and disburses funds accordingly. In 2006, the Board, which had been an unincorporated association, established the Research Foundation as a Texas nonprofit corporation (501 c 3) in order to seek, accept and distribute research funds to members. The Foundation will develop private sources for research funds as well. Trauma Surgeon Resources The Board recruited Dr. Steven Wolf to become the first civilian director of the Burn Center at BAMC. Dr. Wolf joined the Burn Center on 6 April 2004 and directs burn research at the USAISR. Dr. Wolf is an employee of UTHSC on full-time assignment to the USAISR/Burn Center. The NIH transferred Dr. Wolf s RO1 grant to UTHSC; this project is titled Effects of Insulin on Post-Burn Hypermetabolism. Under Dr. Wolf s direction, University Hospital has developed a pediatric burn unit for children 12 years of age and under. Prior to his arrival, all children with significant burns were transferred to Dallas or Houston for care. Other Opportunities for Collaboration coordinated the development of the Regional Trauma Registry and Database project with the state s Regional Advisory Council for Trauma. All of the hospitals providing trauma services in 22 counties, and 35 EMS companies participate by utilizing

8 the same trauma registry software. This is resulting in available, accessible and standardized patient data for clinical research conducted by and other qualified state and national health agencies. Foundation Having proven the value of, the board determined to incorporate as a non-profit corporation in Texas, which was accomplished in January of The Foundation will seek 501 c 3 status with the IRS so that it can pursue private donor funds, reducing its reliance on federal funds. Private funds will supplement donor funds and will help to make stated goals achievable. Key Research Accomplishments The purpose of this grant is not research. Key accomplishments other than research are addressed in the Body section of this report. Reportable Outcomes Not applicable to the purpose of this grant

9 Conclusion is a unique combination of military and civilian trauma and burn centers and will serve as a model of coordinated care, research and education across multiple locations within a city. Preliminary reports illustrate that there are significant opportunities for improved operations and financial outcomes through this collaboration. Given the increasing restrictions on reimbursement for civilian trauma services, whether delivered at civilian or military facilities, it is clear that any opportunity for increased revenue outside of government subsidization is advantageous. Generating increased revenue in these programs enhances our ability to conduct independent investigator-initiated research, extend training inside our institutions and beyond, and solidify the presence of much-needed Level 1 trauma services to civilians and military services. Most of these improvements will not be possible under current regulations that prevent military treatment facilities from billing private insurance companies for care delivered to civilians. The vision for includes becoming the primary site for trauma and burn research in the U.S. and preserving and building the strength and reputation of the internationally recognized BAMC Burn Center. Measurable improvements due to our work will include: improved survival rates of civilian and military casualties; increased innovation in combat casualty care; improved educational experience for UTHSC and DoD surgical/critical care trainees; improved pre-hospital evaluation and resuscitation; and improved mass casualty/disaster response in South Texas and at the U.S./Mexico border. We will implement initiatives that include a surgical research center of excellence, burn center research and program development, video teleconference technology to connect all centers to each other for purposes of disaster/bioterrorism response coordination and shared professional education, a regional ICU registry that will provide the data needed to further research, and the support infrastructure needed to develop these initiatives. The global war on terrorism presents a critical and increasing need for combat casualty care; since our military partners (BAMC and WHMC) are the only two Level1 Trauma Centers and the BAMC Burn Center is the only ABA-verified burn program in the DoD, trauma training at these sites is critical. US military trauma program directors in Iraq praise the accomplishment of deployed San Antonio trained staff. Physicians, nurses and enlisted members from the Army and Air Force utilize their skills obtained from daily trauma training in their respective Level 1 Trauma Centers. The intangible aspects of experience and confidence, derived from direct clinical practice in the military's only level I trauma centers, continues to save lives on the battlefield. Continued research and clinical studies enable us to develop new protocols for trauma management that will save soldiers in future conflicts and victims of trauma at home.

10 I. EXECUTIVE SUMMARY Purpose PHYSICIAN BILLING REPORT July 26, 2004 contracted with Bishop + Associates to conduct a financial assessment of the University of Texas and military medical staff located at Brook Army Medical Center (BAMC) and Wilford Hall Medical Center (WHMC). The scope of the project also includes estimating incremental reimbursement and operational enhancements to billing activities to support the continued provision of high quality, cost effective trauma care for the San Antonio region. Findings Documentation and accurate coding of physician care is a significant issue for UPG. On the military side, charge capture is a major issue. Overall reimbursement of 18% of billed charges for UPG reflects a large opportunity for improvement. Reimbursement on the military side for civilian trauma care is negligible, in spite of 20-30% of the military volumes being provided to civilians. There is a lack of knowledge of effective billing and collection strategies for trauma cases on the part of the billing staff. Potential Reimbursement Enhancements Taking into account all trauma related specialties (trauma surgery, ortho, neuro, plastics, etc.) the impact of a implementing a consolidated approach to trauma billing has the potential to: Increase billed charges between $7-$10 Million Increase reimbursement between $4-$5 Million Increase reimbursement rate from 18% to 40% Consolidated Trauma Billing Program Organizational Structure The recommended structure at the present time is to have contract with UPG to conduct billing services for all trauma physician specialists. This structure will require creation of a separate workgroup within UPG that will focus on the entire billing operation for trauma cases. This workgroup will consist of approximately 6-8 full-time equivalents.

11 CTBP Operations Specific roles are outlined for the key parties involved in the implementation of the new billing process; physicians, billing staff, and the hospital. The specific components of the billing system are outlined. In addition, the billing program process is outlined in significant detail. This outline encompasses four phases; from patient identification through monthly reporting of billing activities. Implementation tasks are identified. Those tasks include preparation and execution of contracts, credentialing of military physicians, updating fee schedules and development of forms, and development of systems. Key Performance Indicators & Accountabilities Development and implementation of a new approach to trauma billing is outlined in detail in the report. Specific and objective performance indicators have been developed so that the program can be monitored and managed effectively. Significant improvement in UPG s current reimbursement performance on trauma is critical to the future of trauma care for the San Antonio region. 2

12 II. FINDINGS OF UPG TRAUMA SURGEON BILLING ASSESSMENT contracted with Bishop + Associates to conduct a financial assessment of the University of Texas and military medical staff. Thirty (30) operative reports from UPG Trauma Surgeons were provided. In addition, discussions were held with staff from the two military hospitals. The assessment included a review of the following key components of trauma surgeon physician billing: Evaluation & Management Documentation & Coding Procedural & Diagnosis Documentation & Coding Pricing, Fee Schedules, & Managed Care Contracting Billing Processes including Compliance Issues Funding Source Assessment Financial Performance Enhancement Strategies EVALUATION & MANAGEMENT DOCUMENTATION & CODING The purpose of this evaluation is to provide a comprehensive review of trauma surgeon evaluation and management coding. a) Physicians are not documenting their time for critical care services and are not including total time in their dictated notes. b) Standardized and accurate documentation of Evaluation and Management services rendered is required to assure complete and compliant billings. The use of preprinted rounds cards filled out by the physicians in a timely manner will accomplish this. c) Physicians dictation was not clear, concise and comprehensive. Physicians are leaving out essential information in their operative reports. Physicians are not documenting evaluation and management services or minor procedures. PROCEDURAL & DIAGNOSIS DOCUMENTATION & CODING Our highly credentialed and expert coding staff reviewed 30 general surgery operative reports and codes and noted the following findings regarding procedural and diagnosis coding, and the use of modifiers. Surgery codes should identify all procedures and services provided with maximum and appropriate diagnosis coding including payer specific modifiers. These processes assure that maximal payment for the higher levels of care rendered for trauma cases are achieved. a) Dictated reports are required in order to correctly assign procedural and diagnosis codes. 3

13 b) Diagnosis codes were not linked appropriately with the procedure or service to receive correct reimbursement. c) The physicians dictation does not clearly state indications or findings. E codes (Cause of Injury Codes) were not able to be determined due to the limited documentation in the operative reports. The use of E codes is vital when billing insurance carriers for trauma services. d) In teaching hospitals, use of GC modifiers when billing Medicare is a common billing practice in order to receive reimbursement for attending physician services. Medicare will not reimburse claims for physician services in a teaching hospital if the modifier is not used. e) Due to a lack of prior indication and notation that the patient was in post operative, determination of correct modifiers is not possible. f) All operative reports provided were for general surgery cases. Modifier 22 for trauma exploration should be used to document this service. When billing with this modifier a letter of explanation is required. (Sample letter provided as attachment) g) When billing for Central line insertions, fluoroscopy is not being indicated. Code per AMA is a separately billable service. PRICING, FEE SCHEDULE, & CONTRACTING This component of the medical staff assessment included review of existing fees by CPT code compared to 275% of the Medicare Allowable fees. In addition, reimbursement by payer class was also reviewed and compared to benchmark data. a) An analysis of UPG s professional fees reflects a range of 129%-1,253% of current Medicare Allowable fees being charged for trauma services, with an average rate of 390%. National norms for trauma reflect a range of 275%-300% of Medicare Allowable in order to assure maximum levels of reimbursement across all payer categories. b) In addition, the current fee schedule reflects a range of $48-$468 per relative value unit being charged, with an average of $146 per unit. c) The overall reimbursement rate for UPG trauma surgeons is 18.2%. This represents less than one-half the physician reimbursement rates compared to regional, State of Texas, and national norms for trauma physician reimbursement. 4

14 d) With a reimbursement rate of 33% on commercially insured patients, it is apparent that trauma has not been carved out of MCO contracts, and that there are large discounts being taken on trauma. BILLING PROCESSES Trauma billing and collections practices are very unique and most trauma centers experience a significant improvement in payments by focusing collections with only certain individuals designated to the trauma service. At the present time, there is no coordinated billing system in place. Trauma surgeon billing is conducted within the UPG billing department with other physician specialty billing. There is a general lack of awareness of the unique nature of trauma patient coding, charge, and reimbursement issues by billing personnel. Patient Registration/Demographic Information Successful billing is based on strong patient demographic information links between the hospitals, trauma physicians and trauma billing staff. a) At UPG, Bishop+Associates found fragmented information flows between these groups. b) There is a lack of, and poor quality demographic information being collected on trauma patients. This information is the foundation for maximum reimbursement and is not being pursued aggressively. Charge Capture Charge capture is another critical component of the billing system. Follow-up can only be done on those charges that have been billed. a) Our findings reflect a significant issue with charge capture in the military hospital setting. b) Billing staff are holding charges until after discharge which causes unnecessary delays in receipt of reimbursement. In some cases, there may be a 40 day delay in getting charge documents to the billing department. c) Physicians should be accountable for submitting charges within 5 days of trauma services being rendered. Collections and Appeals Fragmented and disjointed coding, documentation, billing, and collection processes prevent problematic trauma accounts from being pursued aggressively. 5

15 a) The current collection process is operationally ineffective, with very little aggressive follow-up with respect to low reimbursement or outright denials for payment. b) Lack of accurate documentation affects reimbursement and limits any appeal process effectiveness. There is generally a lack of incentive to pursue reimbursement from payers to improve reimbursement of physician professional fees from trauma care. This significantly contributes to the large financial losses for UT in the provision of trauma care. MILITARY HOSPITAL FINDINGS A cursory review of billing systems and processes was done at BAMC and WHMC. The following findings are relevant to the project s objectives: a) Military physicians are effectively documenting the care provided. b) Existing military professional fees will need to be reviewed and enhanced for billing of non-military trauma cases. c) Charge capture is a major concern in the military setting. 6

16 III. ESTIMATED TRAUMA SERVICE REVENUE & REIMBURSEMENT UPG trauma surgeon charge and reimbursement data was provided for the fiscal year 9/02 to 8/03. Based upon anecdotal information, sixty-five (65) percent of the total was estimated to represent trauma. The balance of thirty-five (35) percent was estimated to represent emergency care provided by the trauma surgeons. This consolidated analysis also considered charges and reimbursement for the military hospitals for civilian patients. However, since the military hospitals include billing for physician services with hospital charges, the physician charges and reimbursement for purposes of this analysis are assumed to be zero. It is assumed that trauma care provided to military beneficiaries is based upon cost formulas, and not within the scope of the project. Therefore, current consolidated trauma surgeon physician fees for civilian care for the three hospitals are estimated at $3,084,897. Current collections are estimated at $560,827, or 18.2%. This is an exceptionally low reimbursement rate for trauma care compared to national benchmark data from the National Foundation for Trauma Care. Assuming similar volume from the fiscal year of 3,767 non-beneficiary cases meeting ACS trauma patient criteria, anticipated annual projected charges and collections for all trauma service specialists (trauma surgeons, ortho, neuro, plastics, etc) and attainable with improved billing processes using a financial model developed by Bishop + Associates are as follows: **********CURRENT************** ********OPTIMIZED*************** *********IMPROVEMENT************ Facility Charges Reim. Charges Reim. Charges Reim. Reim. % UPG 10,797,141 1,962,893 12,581,744 3,881,469 1,784,603 1,918, % BAMC 0 0 5,259,751 1,746,990 5,259,751 1,746, % WHMC 0 0 6,153,623 2,270,979 6,153,623 2,270, % Total 10,797,141 1,962,893 23,995,118 7,899,437 13,197,977 5,936, % Achievement of 75-90% of the optimized reimbursement would bring an additional $4- $6 million dollars in incremental reimbursement for trauma care for the three facilities. Implementation of a separately managed and staffed, discreet consolidated trauma billing program (CTBP) for all trauma specialists providing care to trauma patients has the following opportunities: Increase in billed charges of approximately $7-$10 Million Increase in collections of approximately $4-$5 Million Estimated improvement in collection rate from 18% to 40% 7

17 IV. CONSOLIDATED TRAUMA BILLING PROGRAM (CTBP) ORGANIZATIONAL STRUCTURE Definition and Purpose Unlike a typical trauma center where up to 150 physicians in 15 specialties will be on a call panel, UHS has a faculty practice employee-model where trauma surgeons and other surgical specialists handle virtually all trauma cases. BAMC and WHMC are military hospitals staffed and operated by military personnel. For UHS, the faculty practice requires the surgical specialists to sign Managed Care Organization (MCO) contracts discounting their fees, so when they treat a trauma victim, at best they get paid low MCO rates. Billing for auto insurance, victims of crime and other unique sources is also problematic. The solution is a consolidated trauma physician billing program (CTBP) that functions like a trauma multi-specialty medical group which can shun MCO contracts and help streamline the billing process. The purpose for forming a consolidated trauma billing program is to optimize physician professional fees which will strengthen the San Antonio region Level I trauma care being provided at UHS, BAMC, and WHMC. Doing so will significantly reduce the large financial losses being incurred at the present time. Participation This plan outlines the specific components of the program along with the steps needed for its successful implementation and operation. Initially, participation in the CTBP from the three hospitals will be limited to the trauma surgeons. Over time, orthopedic, neurosurgery, plastic and other low volume specialty surgeons will participate as well, in order to optimize physician revenue for all surgical specialists providing trauma care. Other specialties should achieve the same kind of financial improvement based on an increase in trauma charges of roughly 20%. This amount was determined by using the B+A proprietary physician billing model and payer mix. Benefits of Using a Consolidated Approach The benefits of using a consolidated approach to billing for trauma include: Enables higher fees that reflect challenging nature of trauma care Improves the trauma physician s documentation of services Assures expert coding, systems and training Circumvents MCO/PPO discounts on professional fees Aggressively appeals down coding and denials Effectively collects from trauma care s unique payer sources 8

18 Two Organizational Alternatives; Build versus Buy understands the functions the CTBP will undertake once developed. A CTBP is challenging to establish and operate. Two organizational alternatives for have been carefully considered by B+A. 1. Organize a new sponsored physician group of civilian and military trauma surgeons. then establishes an organization to bill and collect physician fees. (Build decision) 2. Have UPG provide the staff and conduct distinct billing and collection services for the existing UPG trauma surgeons. Within a predetermined timeframe, bring the military trauma surgeon billing activities into the same separate and distinct work group. Additionally, billing activities for civilian and military trauma specialists (ortho, neuro, plastics, etc) will be incorporated into the work group. (Buy decision) At this time, the preferable alternative is the buy decision. This alternative has many advantages over the build decision. A CTBP managed by UPG will be developed to support improvements to existing physician reimbursement and to efficiently contract with payers that require a relationship with the Trauma program. Advantages/Disadvantages of Each Alternative Building a new organization to bill for physician services will Require significant upfront capitalization Encompass a lengthy start up period Likely not meet the approval of UT-Austin Create conflicting objectives for the new Chairman of Surgery at UHS Provide an opportunity to design a system for maximum potential Establish performance accountabilities up front Allow coordinated recruitment efforts based upon performance criteria Utilizing UPG to bill for physician services will Require creation of a department within an already established workgroup Reinforce physician concerns regarding accountabilities and performance of UPG Run the risk of experiencing the same low level of reimbursement Capitalize on existing UPG capabilities, resources, and knowledge Require minimal upfront capitalization Allow for much quicker implementation 9

19 Allow to focus on other goals (funding, research, etc.) Provide an opportunity for UPG to leverage performance improvements from this initiative Staffing: Structure, Levels, and FTE s An estimate of required staffing for billing of 3,500 to 4,000 trauma cases per year on behalf of would include: Billing Manager-1.0 FTE Coding/Billing Representatives FTE s Collections Representatives FTE s Data Entry Coordinators FTE s Staffing levels will be highly dependent upon: Electronic capabilities of the billing processes Level of experience of staff in ED/Surgical billing and collections Managerial effectiveness Alignment of Performance Goals with Achievement Steering Committee A Steering Committee should be established to oversee the organization and performance of the consolidated trauma billing program (CTBP). The Steering Committee can provide a forum for physician input on billing issues as well as create policy to fine-tune the billing process. In most instances, the Steering Committee handles issues which can impact hospitals overall; (resident coverage, etc.). B+A suggests the following participants for a 3 6 month period: Sharon Smith,, Project Coordinator Dr. Ronny Stewart, UHS, Trauma Director Col. Toney Baskin, BAMC, Director Trauma Surgery Col. Donald Jenkins, WHMC, Director Trauma Surgery Ed Grab, UPG, CEO 1 Representative from each Hospital Agreements/Contracts Legal counsel may need to draft a services agreement between UPG and. The characteristics of the billing and service agreement are as follows: Seeing all patients that meet Texas state trauma center criteria and ACS requirements 10

20 Agreeing to allow UPG to bill and collect on their behalf, with the actual services provided by contract with UPG Providing timely, complete and accurate documentation for coding and billing purposes Maintaining trauma service coverage and other hospital requirements Completion of Payer Credentialing Requirements Appropriate billing fee 11

21 V. CONSOLIDATED TRAUMA BILLING PROGRAM OPERATIONS ROLES AND RESPONSIBILITIES The key to an effective billing system is to connect the necessary resources and staff, thus creating a collaborative system. The main roles and responsibilities are as follows: Role of Trauma Physicians Assign billing on all trauma patients to the UPG Trauma Billing Department Provide timely, complete and accurate documentation Provide input on development of the program Over time, increase scope to assure all trauma surgical specialists are participating Role of UPG Trauma Physician Billing Department Contract with Establish a separate and discreet Trauma Service Billing Department Send out HCFA 1500 claims with appropriate documentation in a timely manner Provide monthly statements to patients Carry out aggressive follow up of outstanding claims Follow established appeal protocols Post payments to the billing system in a timely manner Prepare month end reports for, multi-hospital administration, and key physicians Assure creation of a multi-disciplinary work team for trauma billing Build effective communications among all patient financial services departments Role of Hospitals Provide view only access to registry for billing Provide view only patient demographic information (this will also help improve hospital collections) Assure Medical Records availability for billing BILLING SYSTEM COMPONENTS Patient Identification/Information System The trauma program should identify all trauma patients coming into the hospitals by state or ACS trauma triage criteria. The trauma program should issue a daily trauma 12

22 log from the trauma program by patient name, medical record number and physician highlighting demographic information that may be missing. Capturing current trauma patient demographics is important to a successful billing program. Fee Schedule To assure adequate levels of reimbursement, national norms for trauma surgeon fees are set between 2.75 to 3 times Medicare s RBRVS (cognitive or procedural) participating provider reimbursement. The current UPG fee schedule should be revised to insure consistency of the conversion rates across all CPT codes. For example, CPT code has 5.44 RVU s attached to it times $35.47 current Regional Medicare conversion rate = $193. UPG s current charge for is $822 but should be decreased to a range from $481 $578. The fee schedule should also be revisited each year when Medicare updates the conversion rate. Medicare geographic price indexes should also be reviewed each year (see the attached Excel spreadsheet). Contracting A program billing exclusively for trauma services and procedures for all trauma specialties enables the physicians to charge a higher rate for trauma keeping it separate from other physician contractual rates. The fact that trauma is unique needs to be conveyed to the third party payers. Trauma physician services should be removed /carved out of existing managed care contracts so that payers begin paying for the increased costs incurred in the treatment of trauma patients. Charge Documents The physicians must use a standard charge ticket/document to indicate the level of E/M service, diagnosis and if a procedure was done. This must be completed for both admitted trauma patients and trauma ER patients. Current anecdotal information suggests that UPG may not be capturing all trauma critical care and resuscitation charges due to resident coverage, high level of activity, and patients leaving AMA. Professional Fee Coding The trauma service should bill for all procedures and services by CPT code at the maximum appropriate unit value, including relevant modifiers, coupled with appropriate diagnosis codes. All of these processes enhance revenue and assure maximum payment for the higher level of trauma services provided. In an optimized billing process, CPT and ICD-9 codes are selected based on the physician s dictation in the form of clear and comprehensive operative notes. These documents must contain specific information critical to higher reimbursement. 13

23 The physicians should code all their E/M services and indicate the patient s diagnosis in written form. Insurance type will not impact the physician process, but does affect the coder and their use of modifiers. Software and Hardware An assessment of UPG s existing software and hardware will need to be made to determine its capabilities relative to operation and management of a separate and distinct trauma workgroup. UPG should be linked to UHS, and eventually BAMC and WHMC s financial systems to allow retrieval of patient demographic information. Payment Posting System UPG will modify existing systems or establish effective systems for follow up and appeal processes. Use of a lockbox for receipt of payment notifications for trauma physicians is recommended. Payments should be posted to the patient s accounts from the copies of checks and EOB s received from the lockbox. Use of a managed care contract reporting system can efficiently identify underpayments. Reporting Systems Development of a reporting system specific to trauma physician services rendered to patients meeting ACS or Texas state trauma criteria is required. This system would reflect charges and collection amounts for individual patients, as well as monthly and yearly totals. This system will provide information to measure efficiency, effectiveness, and accountability of the billing service. Monthly or quarterly meetings between the trauma physicians, the trauma billing management and staff are an important part of the collaborative process. These meetings will address paper flow problems, review month-end reports on the productivity of the trauma physicians, and review current collections and charges. This is also an opportunity to review difficult cases with the physician(s) for assistance with the appeal process. An information vacuum can occur that favors the payer and the patient and reduces physician income without detailed reporting systems. This can be corrected by developing a comprehensive trauma physician management report package that accurately tracks the accounts receivable status of each case. BILLING PROGRAM PROCESS Phase One: Information Gathering 1. Identification Process of all Trauma Patients 14

24 The trauma programs will identify trauma patients by ACS/state trauma guidelines when each hospital receives them. A unique number will be assigned to each trauma patient. UPG will rely on the primary demographic findings of the hospitals, thus requiring a close working relationship on registration information. The trauma registries will create trauma logs listing trauma patients by name, medical record number, and physician. These lists will be sent directly to UPG Trauma Billing Program to distinctly identify trauma patients from the other nontrauma hospital patients. 2. Collection of Demographic Information UPG s Trauma Billing Department data entry personnel, with view only access to the three hospital s patient registration systems, will access the systems and collect the trauma patients registration information. UPG will need access to the hospitals registration systems with notification of changes to patient accounts for up to 60 to 90 days. 3. Physician Documentation of Care Physicians should use preprinted rounds card to document their evaluation and management services. History & Physicals, consultations, and critical care notes will be dictated. All minor procedures and operative procedures will be dictated and copies of all dictated reports and rounds cards will be sent to the UPG Trauma Billing Department. Phase Two: Professional Coding for Surgical Procedures 1. Professional Coding Surgical and minor procedures will be forwarded to UPG for professional coding. UPG will code using appropriate modifiers and ICD9-CM codes. In addition, the surgical coding worksheet will be used to document the coding process. Phase Three: Billing Process Enhancement of the existing billing and collections systems will significantly increase physician professional fee revenues. 1. Information Review and Data Entry Registration received from the hospital will be reviewed by UPG Trauma Program billing staff for accurate and complete information. Appropriate staff should check the hospital systems for updated information on a periodic basis (daily, weekly). Self-pay patients will receive a statement of charges immediately; this will also serve as a request for insurance information. Data entry will enter the charges from the preprinted physician s rounds cards or the surgical coding worksheet. 15

25 2. Generation of HCFA 1500 Claim Forms The system will generate for UPG the HCFA 1500 claim forms. Claims should be reviewed by experienced staff for accuracy and checked that all necessary reports for trauma consults, History & Physicals, minor procedures, and surgical cases are included. Reports do not need to be attached for hospital visits. 3. Account Follow-up A protocol should be developed that concentrates the collection efforts for this unique patient population. This includes knowledgeable staff that can deal with and focus their efforts on the complexities of trauma care only. Insurance claims should be aggressively followed up when they have been out to the carrier over 60 days. All follow-up activity should be noted utilizing the electronic note feature of the billing system. At a minimum, the following information should be tracked within the note feature: date, time, activity (call, letter, , etc), contact name and other pertinent information for future reference. Carriers should be educated on the unique nature of trauma services and its billing intricacies in a proactive manner. Carelink and other Bexar County aid programs should be aggressively considered for possible sources of reimbursement on all uninsured patients. The collectors will track payments by payer closely and monitor trends in underpayment that would otherwise go unnoticed. Only when knowledgeable and skilled individuals who understand the nuances of trauma are conducting the billing functions, will collections increase. 4. Appeals Process An aggressive appeals protocol should be established for denied or low reimbursed charges. In a typical trauma surgeon practice, an aggressive followthrough process to deal with low reimbursement or denials for difficult cases can increase income significantly. An organized approach to appeals should be taken and be the responsibility of the trauma collectors. Appeal protocols will include an appeal letter, copy of the original claim, and all required reports (copy of an appeal letter is attached). Appeal letters should be sent to the carrier, with follow-up beginning 60 days from the date the appeal letter was sent until resolved. On all difficult cases the trauma surgeon should be involved in the appeal process to help in clarifying the complexities of the case. 5. Payment Posting 16

26 Payments are posted to the accounts on a daily basis from copies of checks or EOB s received from the lockbox. The payment posting staff should forward all EOB s to the auditor/collectors in order for the appeal process to be initiated. 6. Statement Processing Once a month, statements should go out to all patients with an open balance; dunning notices should be included on the statements. When a balance is the responsibility of the patient, a letter should be sent indicating the amount due and why the patient is responsible (i.e. after insurance payment, non-coverage issues, etc.). The name of the patient account representative assigned to each account will be referenced with their direct phone number on the statement. 7. Collection Activities There should be automatic letter generation capability in the billing system utilized by UPG in order to efficiently generate pre-collection letters to patients. Accounts that have had no response from the patient and have aged over 45 days should be reviewed for possible transfer to a collection agency. A final collection letter is sent certified with a return receipt showing that the patient or agent has signed for the notice. When asking the patient to sign a lien, focus on the patient being responsible for payment. This is critical whether or not litigation is pending or other parties may be ultimately found responsible. A lien program that runs in conjunction with the hospital clearly benefits the trauma surgeons. Where legally possible, the patient must be held responsible for payment of services despite any pending liability, lawsuit or third party involvement, none of which erases the patient responsibility. 8. Small Balance Write Offs UPG Trauma Billing Department needs to propose to a dollar limit for small balance account write-offs. This amount is usually set at $10.00 to $ An effort should still be made to collect on all amounts due; however, it is not cost effective to spend more in staff time to collect on a balance that is under a certain established dollar limit. Phase Four: 1. Accounts Receivable Monthly Reporting System At the end of each month, reports will be run and then reviewed by the trauma staff. Reports will be broken down by hospital, specialty group, individual physician within the group, or other means as determined by the department. The reports will include: 17